Healthcare Provider Details

I. General information

NPI: 1316231764
Provider Name (Legal Business Name): ARIANA JAVANEH INGSTAD O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2011
Last Update Date: 06/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79795 HIGHWAY 111
LA QUINTA CA
92253-4756
US

IV. Provider business mailing address

79795 CALIFORNIA 111
LA QUINTA CA
92253-4756
US

V. Phone/Fax

Practice location:
  • Phone: 562-522-1139
  • Fax:
Mailing address:
  • Phone: 562-522-1139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13936
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: